Mr. Bernard Gloster:

Good morning. I thank the committee for the invitation to attend today’s hearing, together with colleagues from the National Treatment Purchase Fund, to discuss the management of waiting lists for hospital treatment and the insourcing and outsourcing of such treatment. I am joined today by my colleagues, as outlined by the Chair, and supported by my general manager, Ms Niamh Doody.

Waiting lists for healthcare have long been a challenge in several jurisdictions, with various attempts to respond to increased demand through capacity measures, reform and special initiatives. OECD reports, including in 2020, note that various policy attempts in different countries and getting the right policy mix are dictated by the health system specific to an individual country. The balance between short-term initiatives helping, but only in the short term, together with additional capacity being overtaken by increased demand are indicators that successful policy direction is not binary when it comes to this aspect of our health system. I have previously noted at meetings of health committees that the one absolute shared experience internationally is that the focus is and needs to be on time waiting rather than the traditional narrative of volume waiting.

Reviewing waiting lists in Ireland for 2023 and 2024 gives us some perspective on how a focus on time waiting is, without doubt, in the public interest. We have shown through a combination of approaches that we can substantially disrupt the time waiting. For example, at the end of 2023, we reduced the overall average waiting time, improving on the previous year from 9.2 months to 7.2 months. The numbers waiting more than four years reduced by 85% when, through a targeted focus, 29,000 people from that category were removed, leaving an unprecedented low of 5,000 people. For this to be effective, the three-year list also had to be tackled and this was reduced by 81%, with 57,000 removals from that category, also leaving a new low figure of 13,000. These outcomes were against an increase of almost 188,000 more additions than in 2022. That is a growth of new additions to waiting lists of 12% and an enormous 23% more in new additions than in 2019.

At the end of 2024, the weighted average wait time for outpatient departments moved to 6.8 months, down from 12.2 months in 2021. Improvements were made to inpatient and day-case times, which were down from eight to six months, and in gastrointestinal scopes, times reduced from nine months to 2.7 months. Some 85% of all patients on the key hospital waiting lists at the start of 2024 were seen, treated and removed by the end of the year. This is again despite further unprecedented growth in new referrals.

These improvements are welcome and impact on the lived experience of people. They have been achieved through a set of measures and reforms, including capacity building in workforce and infrastructure; new contract arrangements; target setting and measurement in the form of Sláintecare; new approaches to the Did Not Attend challenge; modernised pathways; and trialling of different patient initiatives in the form of central referrals and patient-led reviews. All of these together came with increased investment.

It is equally the case, however, that the pace of reform has presented challenges in the context of increasing demand. Such was the demand post-pandemic that our projection methods were greatly challenged. Thankfully, we believe we have got to grips with this in 2025. Reform has been slow in some respects and achieving it both timely and consistently is now our greatest priority. We will only know this has occurred to a satisfactory degree when our capacity and productivity combined bring us from circa 32% of people waiting inside Sláintecare timelines to that being the experience of all. Regardless of how improved we have made it for those outside the Sláintecare target, all our effort must be focused on that single goal.

It is also important to recognise that we have had to, and continue to, use other measures to complement reform. The experience of the public in waiting times would be totally unacceptable if we did not take additional steps. The unintended consequence is we have developed an unsustainable reliance on short-term measures, such as insourcing. This is coupled with outsourcing, which has been a feature of our system for 20 years since the establishment of the NTPF.

In 2023, I commenced examination on some of the issues of outsourcing and insourcing and published an internal audit report in 2024 in a small number of hospitals. This was at the time more concerned with ensuring adherence to procurement and other financial regulations. In 2025, the Minister for Health, Deputy Carroll MacNeill, requested I conduct a nationwide review with particular focus on insourcing, specifically dependency and activity. This week I submitted my report to her. This is the report the Chair referred to, which was published last night by the Minister.

Taking an extract from that report, prior to its publication, I reviewed a 27-month period across 2023 and 2024 and quarter 1 of 2025. This was to identify the scale of dependency. For clarity, the definition is what I referred to when discussing this activity called insourcing:

Insourcing refers to the practice of engaging external companies or third-party providers to deliver services often outside of normal working hours, using HSE-owned facilities and equipment. In many cases, these providers may employ or subcontract staff who are already directly employed by the HSE, effectively re-engaging internal staff through a separate commercial arrangement, typically at premium rates. It is not the use of standard overtime within employment contract arrangements of existing staff which is a different form of insourcing.

Some of the key observations from this survey indicate that, through the course of the 27-month period, €1.1 billion is the identified combined spend on these two areas of patient service provision, with 73%, or €830 million, being in the acute setting and the greatest amount of that being in outsourcing. Within acute settings, some €739 million of the spend is outsourcing and this ranges from private hospital care to private ambulances to laboratory products. That is to say, not all outsourcing is for waiting list management. Within acute settings, between €71 million and €91 million appears to be insourcing. For caution, the rounded figure of €100 million is used here. That is because we have validated some €71 million, with €20 million yet to be defined. This gives the figure of €91 million. As I said, for rounded figures for this discussion, €100 million is the appropriate figure.

Regarding activity, it is important to put the instances of care for the waiting lists we are addressing into context. The following shows the number of instances of care we can see through our core work versus outsourcing and insourcing in the period measured. Members can clearly see that in the period measured, on the three key waiting lists on which we are focused, 13,211,000 instances of care were provided through our normal service plan activity or what we call core business. The initiative-funded or extra purchase of outsource activity can be seen in the form of the NTPF, at 171,000, and the HSE had some additional 26,000. Insourcing combined between NTPF and HSE special waiting list funding reaches a figure of more than 500,000 instances of care. This indicates that in waiting list management, we have developed an overreliance on insourcing to supplement our core activity.

Insourcing, by its nature, carries risks and having assessed these, I have agreed with the Minister and the Department the need to take a series of steps which first reduces those risks and increases safeguards and, second, removes our dependency on insourcing. I hope to finalise those steps when the Minister has had an opportunity to consider the report in full. Any next steps at her direction will be communicated clearly.

I record my thanks to the many staff across the health service who come to work every day to improve patient and social care in all our settings. I equally recognise that today there are people who will be waiting for a consultation, procedure or other service and for them, that wait is simply too long. I apologise to them and recognise that regardless of our improvements and progress, we simply have to do better. It is therefore important that our policy and procedure steps are carefully considered, balancing all the variables of demand, capacity, productivity, reform and short-term initiatives.